Early Social Functioning May Predict Long-Term Outcome in Psychosis

Social functioning appears to be a useful indicator of long-term outcome in people with psychotic disorders and may be an important treatment target that could lead to improvements in other areas of functioning, according to a study posted December 16, 2016, in AJP in Advance. The lead authors were Eva Velthorst, Ph.D., of the Icahn School of Medicine at Mount Sinai, and Anne-Kathrin J. Fett, Ph.D., of the VU University in Amsterdam.

The findings suggest “that there is an unmet need in a large subgroup of individuals with enduring social impairment that lasts into the later illness stages,” Velthorst and Fett told Psychiatric News by email. “If social impairments are present, they often seem to have their onset already before the first psychosis, which highlights the value of early intervention strategies.”

The researchers analyzed data from the Suffolk County Mental Health Project, a 20-year prospective study of first-admission patients with psychotic disorders. They looked at social functioning and long-term outcome in 485 individuals with schizophrenia spectrum disorder (schizophrenia, schizoaffective disorder, or schizophreniform disorder), major depressive disorder with psychosis, and bipolar disorder with psychosis, as well as a control group of individuals who had never experienced psychosis. Social functioning (interest and engagement in social activities and relationships) was assessed at six months, two years, four years, 10 years, and 20 years.

Using statistical analysis, the researchers identified four distinct trajectories over the 20-year period among the individuals with psychosis: preserved functioning (n=82), moderately impaired functioning (n=148), severely impaired functioning (n=181), and profoundly impaired functioning (n=74).

The trajectories of profoundly and severely impaired social functioning were associated with worse 20-year functional outcomes in a variety of domains, such as not having obtained a high school diploma, being unemployed, not living independently, and using public assistance.

Velthorst and Fett also found that differences in the level of social functioning were already evident in childhood. The years between early adolescence and first hospitalization appear to be a period in which a substantial number of individuals who later developed a psychotic disorder displayed a steep decline in social functioning, they wrote.

Although more participants with schizophrenia spectrum disorders had impaired trajectories and more with mood disorders had better functioning trajectories, the study was not able to determine what protective factors “may have protected certain individuals’ social functioning,” Velthorst and Fett wrote.

They continued, “We expected to find subgroups that would deteriorate or significantly improve in social functioning over time, which we did not. It appears that the most important predictor for enduring social impairment in our study is the level of social impairment around and before first hospitalization.”

Velthorst and Fett noted that the findings are consistent with recent programs of research focused on adolescence as the critical intervention window. Those programs support early intervention strategies for high-risk individuals and intensive treatment for first-admission patients aimed at preventing social withdrawal.

“When people think of psychotic disorders they think about hallucinations and delusions. These can often be treated by medications,” they wrote. “However, a large number of individuals diagnosed with a psychotic disorder also experience persistent difficulties in social functioning, even after symptom remission. Treatment options for social functioning are often limited.

“Importantly, our data suggest that the monitoring of social impairment should not be limited to those diagnosed with schizophrenia, but should also be done in different psychotic disorders,” they wrote.

Co-author Roman Kotov, Ph.D., added in comments to Psychiatric News that without treatment, patients who are socially impaired are likely to continue to be so. Although the present study did not examine effects of treatment, previous studies show that some forms of psychotherapy are effective for social impairment. “[C]linicians should consider these interventions for patients whose social functioning is noticeably limited,” he said. ■